The purpose of this study is to examine the state policy environment in which health reform will be implemented, and to explore the effects of health reform on insurance coverage and access to care among low-income Americans. The Affordable Care Act (ACA) expands Medicaid eligibility in 2014 to all Americans with incomes up to 133% of the Federal Poverty Level (FPL) and creates insurance exchanges and premium subsidies for families up to 400%. California has passed legislation to implement these changes earlier, starting in 2011, under the Bridge to Reform program. The need for change is pressing: nationally, 7.5 million children and 42 million adults under 65 have no health insurance, and research demonstrates that lack of health insurance leads to adverse health effects. Furthermore, research shows that eligibility alone does not always improve access to care, due to barriers faced by low-income individuals in insurance enrollment, coverage retention, and obtaining needed services even once they obtain coverage. Thus, the actual impact of the ACA on low-income populations is uncertain, and prior research can only offer limited insight into what will happen under such a dramatic system change as health reform. This proposal contains three projects: 1) An interview and survey with key state Medicaid officials, which will explore each state's priorities and plans for the implementation of health reform; 2) an analysis of the effects of expanded Medicaid eligibility on coverage and access to care in California, which serves as a test case for national health reform; and 3) an assessment of the impact of health reform on rates of uninsurance, stability of coverage over time, access to health care, and racial disparities in care among low-income Americans. We will then identify which state-level policies measured in the survey of state officials are associated with differences in these outcomes, in order to better guide and refine policy efforts in this realm. Th overall objective of this career-development award is to support the candidate (Dr. Benjamin Sommers) at the outset of his career, providing sufficient time to focus his research agenda on these critical issues in health policy. Dr. Sommers is Assistant Professor of Health Policy and Economics at the Harvard School of Public Health, in the Department of Health Policy and Management. This proposal builds on his prior research on Medicaid policy and access to care. Dr. Sommers has assembled an advisory team of leading policy researchers with expertise in health economics, medicine, large database analysis, political science, survey design, and mixed methods research. The department is a vibrant research community that will provide Dr. Sommers with mentorship and support as he embarks on his career as an independent investigator. PUBLIC HEALTH RELEVANCE: Medicaid Policy, Coverage, and Access to Care Among Low-Income Americans Under Health Reform Relevance/Project Narrative (2-3 sentences): This project explores the effects of the Affordable Care Act ('health reform') on health insurance coverage and access to care among low-income Americans. The study will identify the steps that state policymakers are taking to prepare for the expansion of Medicaid under health reform, and will measure the effects of these policies over the next 6 years. Understanding the successes and failures of health reform will be critical in revising the Affordable Care Act and in crafting additional policies to improve access to health care among millions of low-income Americans.